What the 55086 is for
The Initial Disability Insurance Medical Statement starts a short-term disability claim with Alberta Blue Cross. Canada’s life and health insurers have moved to one harmonized initial medical form for short- and long-term disability, and the 55086 is Alberta Blue Cross’s version of it. The insurer decides whether the patient is disabled under the terms of their plan, so it reads Section 2 for current restrictions, expected recovery and return-to-work plans. It is separate from the Service Canada medical certificate for EI sickness benefits, which some patients also need.
Who completes it
The patient completes Section 1: contact details, employer and policy numbers, the date they last worked and expect to return, current medications, height, weight, dominant hand, and the consent to release medical information to the insurer. The family physician, a consulting specialist or another medical provider completes Section 2, the Medical Statement.
Patients often bring the form with Section 1 half done, or leave the medication list for you to fill in. In Medulla, you send Section 1 to the patient over a secure link before the visit. They fill in their details and medications on the form itself, and their answers land on the PDF you complete Section 2 on. Blue Cross gets one complete statement, and you can check their medication list against the chart.
How to fill in Section 2, the Medical Statement
Diagnosis and cause
Give the primary diagnosis and any secondary diagnoses or complications. For childbirth, give the expected or actual delivery date and the type of delivery. Say whether the condition is due to an occupational illness or injury, a motor vehicle accident or another accident. List other disability claim forms you have completed recently, such as CPP, WCB or another insurer.
Treatment and response
Record the first visit for this condition, the first date off work, visit frequency, and the last and next visit dates. List treatment and medications not already in Section 1. Say whether the patient is following the treatment program and whether the response has been complete, partial, none or too soon to tell.
Hospitalization
Give admission and discharge dates, the institution, and any surgery, or attach the reports. Stop here and sign if the patient is back at work or the disability will last under four weeks.
Investigations and clinical findings
For longer disabilities, attach relevant test results, consultation reports and clinical notes. The form warns that tests not attached will be read as tests not performed. Describe symptoms with their history, severity and frequency, and whether they have improved, stayed the same or worsened.
Restrictions and limitations
This is the section the insurer reads most closely. Describe the cognitive and physical restrictions in work terms: how long the patient can sit, stand or concentrate, what they must not lift, and which tasks they can’t safely do. Say whether any licence has been restricted and whether the patient can manage their own affairs. Note contributing factors such as workplace, family or financial issues.
Prognosis and return to work
Give the prognosis for improvement or recovery and the return-to-work goals you discussed, including a gradual return or modified duties if appropriate.
Common reasons it’s sent back
- A diagnosis with no restrictions or limitations described.
- “Off work” with no expected duration or return-to-work goal.
- A disability expected to last more than four weeks with only the first two pages completed.
- No test results or consultation reports attached for a longer claim.
- Section 1 or the patient’s consent missing.
Submitting and who pays
The completed form goes to Alberta Blue Cross Life and Disability Services at the Edmonton address and fax numbers printed on the form. The patient is responsible for any fees for completing it, so the clinic bills them directly.